HTML version of the form: Consent For a Personal Information Request Form
Protected B (when completed)
Consent for a Personal Information Request Form
If your spouse or common-law partner, children 16 years of age or older, or any other individuals whose information could be contained in the requested records wishes to release their information as part of a Personal Information Request made by another individual, they must sign in the space provided. Information about minors will only be released with the consent from both parents (if applicable) or a valid Canadian court order indicating that the applicant is permitted to obtain their information. Obtaining consent from all parties will permit the department to release their information and will provide you with more information in response to your request.
Please complete as many of these forms as necessary. Consenting individuals may be asked to provide identification.
Privacy notice statement
The personal information provided on this form is collected and protected under the provisions of the Privacy Act. It is retained and used as described in Personal Information Bank PSU 901 by the institution to which this form is submitted. Any questions about the collection, use or disclosure of this information should be directed to the Access to Information and Privacy Coordinator of the institution to which this form is submitted. The information is used to process and respond to formal requests made under the Privacy Act, including subsequent requests for correction, complaints, investigations and judicial review when applicable. The information provided on this form is used to record consent for the institution to disclose personal information about another individual to you or your authorized representative in response to a personal information request. It is collected under the authority of sections 8(1) and 13 of the Privacy Act. Failure to provide this information may result in the inability to process your request. You have the right to the correction of, access to, and protection of your personal information under the Privacy Act. You have a right to complain to the Office of the Privacy Commissioner of Canada regarding the handling of your personal information request.
- I acknowledge the privacy notice statement above.
Personal information
- Family Name (Surname):
- Given name(s):
- Current address (address number, apartment number, street, city, province, postal code):
- Telephone, E-mail, Fax:
Information about your request
- Government institution to which you are submitting the request:
- Please describe the request that you are providing consent for:
Consenting individual’s information
- Family Name (Surname):
- Given name(s):
- Date of birth (yyyy-mm-dd):
- Relationship to the Requester:
Signature
By signing this form, you authorize the institution to which this form is submitted to release your information to the requester or their authorized representative. The consent must be signed and dated by the person giving the consent. Only original handwritten signatures signed in blue ink or valid digital signatures will be accepted. Missing signatures may delay the processing of your request.
Please Note
The consent is valid for one year from the date appearing next to both signatures. Please sign in blue ink.
- Requester Signature:
- Date (yyyy-mm-dd):
- Consenting Individual’s Signature:
- Date (yyyy-mm-dd):
TBS/SCT 350-60E (Revised 07/2022)